Continued Discussion On Specialty Care Coordination

“Payers are primarily dissatisfied with their specialty pharmacy’s ability to document the interventions they say they are performing. As pharmacies compete on price and service, they will need to be able to efficiently document the services they perform in order to differentiate themselves in the marketplace.”

— Debbie Stern, R.Ph., president of Rxperts, Inc., an Anaheim-based consulting firm, told AIS’s Drug Benefit News for a story on the new EMD Serono Specialty Digest.

I like this quote from Debbie.  It reminds me of my post from the other day “Care Is Coming To Your PBM” and is very much in line with the article I tweeted yesterday – Pharmacy Chains Continue To Blur The Line.

The point is that complex conditions like oncology are a lot more than simply filling the drug.  To be truly patient-centric, you need to be able to answer all these questions:

  1. Were they diagnosed correctly?
  2. Were they staged correctly?
  3. Did the provider follow evidence-based care?  From NCCN?  From a particular pathway?
  4. Did they get all the genetic tests done?  
  5. Did they get too many tests?
  6. Are they prescribed the right drug?  Will that drug limit any future options for care?
  7. Is the drug covered on formulary?  If not, are there other ways to reduce the out-of-pocket costs to the member?
  8. Is it a limited distribution drug?  
  9. Do they understand the side effects of the drug and/or treatment?
  10. What does the patient want?  What do they know?
  11. Do they have a caregiver?  How are they involved?
  12. Are they getting the drug at the right site-of-care?
  13. Are they working with a case manager?  How is their care being coordinated?  
  14. What’s the survival rate?
  15. Are there implications for ongoing care as a cancer survivor?  How will they be coordinated?
  16. If they need palliative care, what are their wishes?  Does the family, patient, and provider all agree?

Cancer is a great example of where everything comes together from a care coordination, testing, diagnosis, delivery, and pharmacy perspective.  At the same time, we know that patients still see multiple doctors who don’t coordinate their care.  We know they get mis-diagnosed.  We know that don’t stay adherent with their medications.  We know they don’t always articulate their wishes.  And, we know the amount of care spent in the last months of life is disproportionate (IMHO) to the minor life extension which they get (often in less than optimal conditions).  

Here’s a good summary of some key data from the EMD Serono report:


One Response to “Continued Discussion On Specialty Care Coordination”

  1. Bruce A. SEMINGSON Reply June 11, 2014 at 9:12 am

    I have read this summary (several times) regarding the need for coordination of care on the use of Specialty Drugs as well as coordination of care of all medications. First of all the list of questions for complex conditions is excellent. In fact many of these questions should be utilized for most chronic conditions. For many years many of us in healthcare have supported the need for coordination of care regarding prescription drugs (MTM) and yet actual implementation of meaningful programs in minimal. No better example than Medicare Part D MTM. I guess we prefer to just dispense medications and hope that all will be well and if not we will try to fix the resulting problems at great expense and patient peril.

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